Douglas S. Richards

Congenital diaphragmatic hernia : Epidemiology and outcome

Congenital diaphragmatic hernia is a relatively common birth defect. It affects about 1114 babies a year in the United States. Reported survival averages 60% but may be significantly lower. We do not understand the etiology of CDH. Its association with other anomalies and several distinct patterns of presentation suggest that more than one cause may exist. There is a high degree of variability in both treatment and outcomes, but no data exist to allow a rigorous comparison of the efficacy of various treatment strategies. Stratification of patients into more homogeneous groups will be a necessary prerequisite for the design of meaningful comparative trials. The incidence of the lesion prevents any single institution from accruing sufficient patients to conduct such a trial. An ad hoc multicenter study group (the Congenital Diaphragmatic Hernia Study Group) has been formed for this purpose. This organization has begun collecting data with an initial goal of developing a stratification scheme. Prospective data collection should allow verification of several of the estimates made in this article. Current data make it clear that CDH represents a major cause of perinatal morbidity and mortality.

Prediction of fetal macrosomia using humeral soft tissue thickness

Objective To determine the usefulness of an objective assessment of humeral soft tissue thickness in estimating birth weight in a population at risk for macrosomia. Methods Shortly before delivery, ultrasound examinations were performed on 95 women at risk of having macrosomic infants. In each case, the fetal humeral soft tissue thickness (the distance between the outer edge of the humerus to the skin surface on transverse views of the upper arm) was measured three times, and an average was taken. Results The humeral soft tissue thickness correlated significantly with birth weight (R2 = 0.40, P < .001) and ponderal index (R2 = 0.20, P = .02). The humeral soft tissue thickness was significantly higher in macrosomic infants (P < .001), in those with an abnormally high ponderal index (P = .02), and in infants whose deliveries were complicated by shoulder dystocia (P = .05). There was no apparent effect of maternal diabetes on the humeral soft tissue thickness. The humeral soft tissue thickness was more sensitive in predicting macrosomia than was the ultrasound-estimated fetal weight (88 versus 71%), but less specific (75 versus 91%). Conclusion The humeral soft tissue thickness correlates with birth weight. However, its clinical use compared with other predictors remains to be defined.

Correlation of Prenatal Renal Pelvic Anteroposterior Diameter with Outcome in Infancy

PURPOSE We attempted to correlate prenatal renal pelvic anteroposterior diameter with outcome in infancy. MATERIAL AND METHODS Between May 1992 and March 1994 we identified 27 cases of fetal hydronephrosis in which renal pelvic anteroposterior diameter was 4 mm. or greater before 33 weeks of gestation and 7 mm. or greater at or after 33 weeks of gestation. RESULTS Hydronephrosis was bilateral in 18 fetuses and unilateral in 9. Shortly after birth radiological assessment revealed vesicoureteral reflux in 6 neonates, ureteropelvic junction obstruction in 6, extrarenal pelves in 3 and persistent nonobstructive hydronephrosis in 4. Radiological evaluation was normal in 8 newborns. CONCLUSIONS When these screening criteria for hydronephrosis are met prenatally a complete radiological assessment should be done following birth.

Patient acceptance of endovaginal ultrasound.

Objective  To assess women’s experiences and attitudes regarding endovaginal ultrasound.

Preinduction cervical assessment.

The rate of labor induction is increasing in the United States. Methods for quantifying cervical factors have been developed to identify patients who may benefit from cervical ripening before induction. The first cervical scoring systems used digital examination. More recently, cervical ultrasound and testing for the presence of fetal fibonectin have been suggested to evaluate cervical readiness for labor induction, but neither of these methods provides a significant improvement over digital examination. The Bishop score, the most widely used digital examination scoring system, still is the most cost effective and accurate method of evaluating the cervix before labor induction.

The case for routine umbilical blood acid-base studies at delivery

One of the major goals of obstetricians is to prevent fetal asphyxia. Unfortunately, the commonly used clinical indicators (fetal heart rate monitoring, meconium staining of the amniotic fluid, and Apgar scores) do not have acceptable accuracy in establishing the presence of fetal asphyxia. These subjective assessments often overdiagnose fetal asphyxia and on occasion may fail to detect its presence. The only scientific, objective means of diagnosing fetal asphyxia at delivery is through umbilical blood acid-base studies. This test is convenient, noninvasive, and accurate. The routine use of umbilical blood acid-base studies is a major asset to the obstetric team in determining (1) the presence of asphyxia and its consequences, (2) the efficacy of interventions to prevent fetal asphyxia, and (3) the mechanisms responsible for fetal acidosis.

Pregnancy outcome for women with very low levels of maternal serum unconjugated estriol on second-trimester screening.

OBJECTIVE Our purpose was to assess pregnancy outcome for women whose second-trimester triple screen results revealed very low unconjugated estriol levels. STUDY DESIGN Of 44,146 women screened for alpha-fetoprotein, human chorionic gonadotropin, and unconjugated estriol, a group of women with isolated very low unconjugated estriol levels were selected as the study group. Pregnancy outcome was obtained by contacting the referring physicians. RESULTS During the study period 62 women had unconjugated estriol levels at or below the sensitivity of the assay. Fetal death was the most common explanation, accounting for 37.1% of cases. Six cases of early death followed uneventful prenatal visits. Eighteen women had unexplained very low unconjugated estriol levels. Of these 18, four cases of placental sulfatase deficiency were diagnosed. Sixteen of these 18 women gave birth to male infants (p = 0.03). CONCLUSION A very low unconjugated estriol level in the second trimester is associated with increased risk for early death and placental sulfatase deficiency.

Antenatal presentation of a child with congenital lobar emphysema.

Several conditions have been described with prenatal sonography that result in the appearance of a lung mass with mediastinal shift. These conditions include cystic adenomatoid malformation, pulmonary sequestration, and bronchogenic cyst. 1 We describe a case with classic findings of a large cystic adenomatoid malformation of the microcystic type. In addition to a large chest mass, the fetus had a marked mediastinal shift, ascites, and polyhydramnios, findings that portend a nearly universally fatal outcome.2 These findings completely resolved prior to delivery, possibly in response to maternal therapy. After birth, the infants right lung became hyperinflated, with findings characteristic of congenital lobar emphysema. This diagnosis was confirmed pathologically after lobectomy. This case is significant, because it is the first reported instance in which congenital lobar emphysema has been manifested antenatally, and because it suggests a possible medical therapy for some fetal pulmonary tumors.

Nonimmune Hydrops fetalis: Fetal and Neonatal Outcome during 1983–1992

Prognostic factors for survival of 62 fetuses and neonates with nonimmune hydrops fetalis (NIHF) were studied retrospectively. Twenty-eight infants survived ≥28 days which is 45% for all fetuses and newborns diagnosed with NIHF and 61% for liveborns with unresolved NIHF. Univariate analysis identified that mortality was associated with the presence of ≥2 serous cavity effusions and a need for chest compressions at birth. Multivariate logistic regression analysis confirmed that the presence of ≥2 serous cavity effusions was significantly associated with mortality from NIHF <28 days after birth [OR = 48.2 (CI 3.6, 662.9) (p < 0.004)]. We conclude that, compared to published cases from the 1970s and early 1980s, survival of liveborns with NIHF seems improved. The decrease in stillbirths is more notable. The severity of hydrops at birth is the key determinant for survival.

Maternal and umbilical serum concentrations of granulocyte colony-stimulating factor and its messenger RNA during clinical chorioamnionitis

Objective To determine whether women with chorioamnionitis developed elevated serum granulocyte colony-stimulating factor (G-CSF) concentrations and, if so, whether the G-CSF crossed to the fetus. Methods We quantified G-CSF before, during, and after delivery and in the cord blood of 12 women with clinical chorioamnionitis and 12 matched controls. We also measured G-CSF messenger RNA (mRNA) transcripts in mononuclear cells isolated from maternal and cord blood at delivery. Results At study entry, G-CSF concentrations were much higher in women with chorioamnionitis (1397 ± 950 pg/mL, mean ± standard error of mean) than in controls (17 ± 5 pg/mL, P < .05). At delivery, concentrations had increased in both groups (2752 ± 1100 pg/mL in the chorioamnionitis group, 165 ± 61 pg/mL in controls; P < .05). After delivery, G-CSF concentrations had diminished to 839 ± 594 pg/mL in women with chorioamnionitis and to 83 ± 16 pg/mL in controls (P < .05). Concentrations in the cord blood were 2729 ± 974 pg/mL for the chorioamnionitis group and 51 ± 17 pg/mL for controls (P < .05). Granulocyte colony-stimulating factor mRNA transcripts were more abundant in women with chorioamnionitis than in controls but were scarce in all matched cord blood samples tested. Conclusion Serum G-CSF concentrations were elevated during clinical chorioamnionitis, and similar levels were found in maternal and cord serum. Because G-CSF mRNA levels were very low in cord mononuclear cells, the G-CSF in cord serum might be maternal in origin.